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ATRIAL SEPTAL DEFECTS

PATIENT STORY

A 35-year-old woman presented to the Adult Congenital Heart Disease Clinic 1 month after successful caesarean section (C-section) of her second child. A C-section was performed only as a result of fetal distress. She reported that compared to her prior pregnancy, symptoms of increasing shortness of breath in the third trimester that persisted postpartum. At the time of her initial outpatient clinic visit she experienced dyspnea with routine activities.

Her physical examination revealed the following vital signs: blood pressure (BP) 111/72 mm Hg, heart rate (HR) 74 bpm with 98% oxygen saturations in room air. Chest examination demonstrated no evidence of a right ventricular (RV) lift or heave. Cardiac examination demonstrated a regular rate and rhythm with a normal S1 and a fixed, split S2. The P2 component of the second heart sound was not accentuated. There was a soft II/VI systolic ejection murmur best appreciated at the left, upper sternal border. No diastolic murmurs, rubs, or gallops were heard. Extremities were warm and well perfused without clubbing, cyanosis, or edema.

CASE EXPLANATION

Patients with an atrial septal defect (ASD) often have fixed splitting of the second heart sound. However, its absence does not exclude an ASD. The absence of a loud P2 component of the second heart sound minimizes the possibility of pulmonary hypertension. The systolic ejection murmur is consistent with increased pulmonary blood flow.